Gudge Heath Lane Surgery

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective - This means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on the best available evidence. We looked for evidence that staff involved people in decisions about their care and treatment and provided them advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this.

At our last inspection, we rated this key question Good. At this assessment, the rating has remained Good. The service had carried out audits to improve the quality of care provided for people, such as long-term condition monitoring. Staff understood the legal requirements around consent and mental capacity was assessed where appropriate. The service was involved in proactive health promotion services to promote people’s health and wellbeing. The service worked with the local primary care network (PCN) and other healthcare providers to support people’s care.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not always make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them.

During our remote clinical searches, we noted 16 people who had a potential missed diagnosis of chronic kidney disease (CKD), the equivalent of 1% of total of people with confirmed diagnosis of CKD. A review of 5 of those people’s clinical records identified 4 out of the 5 had not been coded as CKD, had not been informed of the diagnosis or had further investigations. Following the review of these clinical records, the service had ensured people who were identified had been reviewed in line with national guidelines.

However, leaders demonstrated systems and processes to ensure people who required recall monitoring were supported and managed. This included inviting people for annual health reviews and long-term conditions reviews for asthma and diabetes, in line with national guidelines. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

Information was shared with staff and other agencies to enable them to deliver care and treatment. Delays in referrals were monitored and audits were carried out to ensure urgent cancer referrals were actioned.

The latest verifiable data from NHS England showed cervical cancer screening uptake at the service averaged 66.9% among people aged 25 to 49, and 72.7% among those aged 50 to 64 who met the eligibility criteria. Both outcomes therefore were below the national minimum targets of 80%. In view of this data, the service told us how it had proactively worked to increase uptake and education in this area. For example, Saturday appointments were available with a GP and a nurse practitioner within the service’s extended access arrangements. Dedicated health clinics had also been implemented where eligible people could book appointments into, such as for coil fitting, cervical screening, and long-term condition reviews.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good service standards.

The service had an induction programme for clinical and non-clinical staff which included information for training, appraisal and guidance for providing evidence-based care. Clinical staff had access to local care pathways and prescribing guidelines with the British National Formulary (BNF).

During our clinical searches, there was evidence of comprehensive assessments and personalised care plans within the records we reviewed. Staff used clinical templates effectively and adapted care for people with complex needs. The service demonstrated an effective system for updating clinical guidelines and protocols.

The service worked well across teams to support people, particularly when people moved between different services.

The service worked with stakeholder organisations such as secondary healthcare providers to establish and maintain safe systems of care for people. For example, staff used a clinical decision support the process to log and monitor referrals which included correspondence from external professionals involved in the people's care.

Furthermore, the service worked with the community mental health team to support vulnerable people through treatment planning as part of a multi-disciplinary team.

The service had a system in place for processing newly registered people’s information and summarising medical records. The service had kept up to date with summarising to ensure accurate information was available for clinicians. There were processes to monitor and manage care when people were moved between services such as after referral to secondary care, or admission to hospital. A review of the service’s clinical system indicated people’s test results were being managed in a timely manner to inform future care and treatment planning.

During our review of the service’s clinical records systems, we found examples of effective plans for the movement of people across multiple services. Referrals and discharge summaries were managed appropriately and considered people’s individual needs, circumstances, ongoing care arrangements and expected outcomes.

The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support.

The service offered a range of health promotion provisions and supported people to make healthy lifestyle choices. For example, we observed the service had blood pressure monitors in the waiting areas to improve the accessibility and empower people to manage their own assessments. Staff supported national priorities and initiatives to improve population health such as smoking cessation, weight management, and screening services. There were also systems in place to follow up on missed appointments for health checks and vaccinations. The service employed a social prescriber that connected and supported people with activities, groups and services that improved their health and wellbeing.

The service routinely monitored people’s care and treatment to continuously improve it. They ensured people’s outcomes were positive and consistent, and met both clinical expectations and the expectations of people themselves.

Outcomes for people were generally in line with local and national averages, such as meeting national minimum targets for childhood immunisations. The service regularly monitored Quality and Outcomes Framework (QOF) indicators and demonstrated they had carried out audits to improve clinical quality. For example, the service carried out an audit in relation to Non-Alcoholic Fatty Liver Disease (NAFLD) in 2024. NAFLD is a condition in which excess fat builds up in your liver. The service identified 50% of people with NAFLD had not had their NAFLD score calculated with follow-up advice in line with national guidelines. NAFLD score interpretation uses thresholds to predict advanced liver fibrosis risk, with specific scores suggesting different levels of concern. The score is comprised of blood monitoring data, age and BMI and national guidelines state those with low scores should have this repeated every 2-3 years. The service’s pharmacy team had ensured clinical staff were aware of the importance to contact people for annual blood monitoring, routine NAFLD scoring and follow-up advice. The service had not yet commenced the second cycle of the audit to identify whether the number of people without a NAFLD score had been reduced.

As part of the service’s audit programme, the pharmacy team had demonstrated the monitoring of risk of people with polypharmacy (the use of multiple medicines) induced Acute Kidney Injury (AKI). The audit, in August 2025 identified 4 people who were at risk or, due to being prescribed associating medicines in combination or already had chronic kidney disease (CKD). The service ensured all people had analysed the risk through medicine reviews and blood monitoring whilst considering and prioritising those with health inequalities through higher prevalence of AKI conditions, such as those above 65 years of age and people of Black, Asian or mixed heritage. All 4 of the people who were identified and reviewed, determined low risk of AKI due to the type of medicine they were prescribed or the service de-prescribed their medicines due to positive outcomes following blood monitoring.

The service had also completed a contraceptive coil audit, between January and December 2024, to evaluate the quality of care related to the fitting, use, and follow-up of intrauterine devices (IUDs or coils). The audit focused on people who received contraceptive coil for those with a womb who can't or don't want to use hormonal contraception and those who were not already pregnant. The audit identified 11 people and reviewed the service’s adherence to clinical guidelines, prescribed medicines with recent medication review, the effectiveness of the quality of records to include reason for fitting and any complications to identify and implement improvements where required. The audit found services met established standards.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff understood the legal requirements around consent. Mental capacity was assessed where appropriate, and consent was recorded accurately in the person’s clinical record. There was evidence of shared decision-making and staff had received training in the Mental Capacity Act. We also found that Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) and Treatment Escalation Plans (TEP) records had been completed in line with national guidance.